Provider Demographics
NPI:1811055700
Name:SIMON, ANJULI IVETTE
Entity type:Individual
Prefix:MISS
First Name:ANJULI
Middle Name:IVETTE
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANJULI
Other - Middle Name:IVETTE
Other - Last Name:WAGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, CSAC, ICS
Mailing Address - Street 1:1613 11 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:BARRON
Mailing Address - State:WI
Mailing Address - Zip Code:54812-9022
Mailing Address - Country:US
Mailing Address - Phone:715-553-0328
Mailing Address - Fax:
Practice Address - Street 1:335 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1479
Practice Address - Country:US
Practice Address - Phone:715-537-6174
Practice Address - Fax:715-537-6848
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15442-132101YA0400X
WI3692125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41008100Medicaid